Opportunities for Increasing Diversity in Orthopaedics Through Virtual Mentorship Programs

Orthopaedic surgery lags in recruiting women and under-represented minorities (URMs). In addition, women and URMs hold fewer leadership roles across orthopaedic subspecialties. This inequity is geographically heterogeneous, with female URM residents and attendings being more concentrated in some areas of the country. For instance, practicing female orthopaedic surgeons are more prevalent in Northeast and Pacific programs. Mentorship and representation in leadership positions play a notable role in trainee recruitment. Video communication platforms offer a novel mechanism to reach historically under-represented students across the country. We reviewed five established mentorship programs focused on women and URMs. Each program emphasized a longitudinal relationship between mentors and mentees. In reviewing these programs, we sought to identify the successful components of each program. Leveraging and integrating effective components already established by conventional mentorship programs into virtual programming will aid in optimizing those programs and improve geographic equity in access to mentorship resources. It is critical to extend the principles of successful mentorship programs to technology-enabled programs moving forward.

Thematic analysis of online discussion forums for soft tissue sarcomas

BACKGROUND AND OBJECTIVES

As there is an increasing reliance on the internet for medical information, patients diagnosed with rare diseases have turned to online community forums to share information about their diagnoses. These forums help patients to gather and share information about their experience with disease. Additionally, these platforms enable patients to build unique connections based on their shared experiences. The objective of this study was to review shared posts in online community forums by individuals with soft tissue sarcomas to better understand commonly discussed themes. This information may improve the physicians' understanding of patients' concerns and feelings at the time of diagnosis and treatment.

METHODS

We entered "sarcoma discussion forum" in search engines to identify internet discussion boards. Four major discussion forums were analyzed, and posts written between January 1, 2017 through May 1, 2022 addressing soft tissue sarcomas present in the upper and lower extremities were collected. Each post was analyzed by the two investigators in three steps (open coding, axial coding, and selective coding).

RESULTS

A total of 506 posts were included in the final analysis. We used twenty-seven axial codes and four selective codes. Emotional Aspects/Connecting with Others was the most common theme (77 % of posts) followed by Information Support: Treatment (38 % of posts), Information Support: Diagnosis (24 % of posts) and Information Support: Recovery (21 % of posts).

CONCLUSIONS

The most prevalent theme was centered on emotional aspects of these patients' journeys, highlighting the importance of providing resources to address emotional support for patients with soft tissue sarcoma and their families.

LEVEL IV

Qualitative research study.

Scapholunate Instability: Diagnosis and Management - Anatomy, Kinematics, and Clinical Assessment - Part I

Injuries to the scapholunate joint are the most frequent cause of carpal instability. The sequelae of these injuries account for considerable morbidity, and if left untreated, may lead to scapholunate advanced collapse and progressive deterioration of the carpus. Rupture of the scapholunate interosseous ligament and its critical stabilizers causes dyssynchronous motion between the scaphoid and lunate. Additional ligament injury or attenuation leads to rotary subluxation of the scaphoid and increased scapholunate gap. Intervention for scapholunate instability is aimed at halting the degenerative process by restoring ligament integrity and normalizing carpal kinematics. In the first section of this review, we discuss the anatomy, kinematics, and biomechanical properties of the scapholunate ligament as well as its critical ligament stabilizers. We provide a foundation for understanding the spectrum of scapholunate ligament instability and incorporate meaningful new anatomical insights that influence treatment considerations. The purpose is to provide an update regarding the anatomy of the scapholunate ligament complex, importance of the critical ligament stabilizers of the proximal carpal row, introduction of safe technique to surgically expose the scaphoid and lunate, as well as pathoanatomy as it pertains to the treatment of scapholunate dissociation. In the second section of this review, we propose a novel ligament-based treatment algorithm based on the stage of injury, degree and nature of ligament damage, and presence of arthritic changes.

Proximal Femur Replacements for an Oncologic Indication Offer a Durable Endoprosthetic Reconstruction Option: A 40-year Experience

BACKGROUND

Proximal femur replacements (PFRs) are an effective surgical option to treat primary and metastatic tumors causing large bony defects in the proximal femur. Given the relative rarity of these indications, current studies on PFR for oncologic indications are generally limited by patient volume or relatively short-term follow-up. Because recent advances in systemic therapy have improved the prognosis of patients who undergo limb salvage surgery for musculoskeletal tumors, data on the long-term durability of endoprosthetic reconstructions have become increasingly important.

QUESTIONS/PURPOSES

(1) How does the long-term survival of cemented bipolar PFRs compare with patient survival in patients who underwent PFR for benign, aggressive, and metastatic tumors? (2) What are common reasons for revisions of primary PFRs? (3) Which factors are associated with survival of primary PFRs? (4) What is the survivorship free from conversion of bipolar PFRs to THA?

METHODS

Between January 1, 1980, and December 31, 2020, we treated 812 patients with an endoprosthetic reconstruction for an oncologic indication. All patients who underwent a primary PFR for an oncologic indication were included in this study. The study cohort consisted of 122 patients receiving a primary PFR. Eighteen patients did not reach a censored endpoint such as death, revision, or amputation within 2 years. Thirty-three patients died within 2 years of their surgery. Of the 122 patients with primary PFRs, 39 did not reach a censored endpoint and have not been seen within the past 5 years. However, the mean follow-up time for these patients was longer than 10 years. The Social Security Death Index was queried to identify any patients who may have died but might not have been captured by our database To allow for adequate follow-up, endoprosthetic reconstructions performed after December 31, 2020 were excluded. The mean age at the time of the index surgery was 48 ± 22 years. The mean follow-up time of surviving patients was 7 ± 8 years. All PFRs were performed using a bipolar hemiarthroplasty with a cemented stem, and all implants were considered comparable. Demographic, oncologic, procedural, and outcome data including prosthesis survival, patient survival, complication rates, and rates of conversion to THA were analyzed. Patient, prosthesis, and limb salvage survival rates were generated, with implant revision as the endpoint and death as a competing risk. Statistical significance was defined as p < 0.05.

RESULTS

Generally, patients with benign or low-grade (Stage I) disease outlived their implants (100% patient survival through 30 years; p = 0.02), whereas the opposite was true in patients with high-grade, localized Stage II disease (64% patient survival at 5 years [95% CI 49% to 76%]; p = 0.001) or widespread Stage III metastatic disease (6.2% patient survival at 5 years [95% CI 0.5% to 24%]; p < 0.001). Primary PFR implant survival at 5, 10, 20, and 30 years was 97% (95% CI 90% to 99%), 81% (95% CI 67% to 90%), 69% (95% CI 46% to 84%), and 51% (95% CI 24% to 73%), respectively. Eight percent (10 of 122) of primary PFRs were revised for any reason. The most common causes of revision were aseptic loosening (3% [four of 122]), infection (3% [three of 122]), breakage of the implant (2% [two of 122]), and tumor progression (1% [one of 122]). Follow-up time was the only factor that was associated with revision of primary PFRs. Neither segment length nor stem length were associated with revision of primary. Six percent (seven of 122) of PFRs were converted to THA at a mean 15 ± 8 years from the index procedure. Survivorship free from conversion to THA (accounting for death as a competing risk) was 94% (95% CI 85% to 99%), 86% (95% CI 68% to 94%). and 77% (95% CI 51% to 91%) at 10, 20, and 30 years, respectively.

CONCLUSION

Cemented bipolar PFRs for an oncologic indication are a relatively durable reconstruction technique. Given the relative longevity and efficacy of PFRs demonstrated in our study, especially in patients with high-grade or metastatic disease where implant survival until all-cause revision was longer than patient survival, surgeons should continue to seriously consider PFRs in appropriate patients. The relative rarity of these reconstructions limits the number of patients in this study as well as in current research; thus, further multi-institutional collaborations are needed to provide the most accurate prognostic data for our patients.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Social determinants of health and race are independent predictors of reduced rotator cuff surgery rates in the Medicare population

BACKGROUND

Racial disparities have been shown to influence rates of surgery for patients with rotator cuff disease. Some individuals have attributed adverse social determinants of health (SDOHs) as potential confounders of this relationship between race and surgery rate. However, there is a paucity of literature observing whether adverse SDOHs and race independently influence rotator cuff surgery rates. Therefore, the purpose of this study was to determine whether adverse SDOHs and race are independent predictors of rotator cuff surgery rates for Medicare beneficiaries.

METHODS

A retrospective analysis was conducting using the Medicare Standard Analytic Files (SAF) data set of the PearlDiver database, observing 211,340 patients with rotator cuff pathology. Univariate and multivariable regression analyses were performed to observe whether race and adverse SDOHs were independent variables associated with rotator cuff surgery rates. To determine whether adverse SDOHs significantly influenced racial disparities, stratified analyses of patients with ≥1 adverse SDOH and those without adverse SDOHs were conducted to compare the odds ratios (ORs) and 95% confidence intervals (CIs) of racial disparities.

RESULTS

Among patients with rotator cuff disease, 21,679 (10.26%) were of nonwhite race and 21,835 (10.33%) had ≥1 adverse SDOH. The variables of nonwhite race (OR, 0.622; 95% CI, 0.599-0.668; P < .001) and having ≥1 adverse SDOH (OR, 0.715; 95% CI, 0.501-0.814; P < .001) were independent predictors of not undergoing surgery. On stratified analysis, there was no significant difference in racial disparities in patients with ≥1 adverse SDOH (OR, 0.620; 95% CI, 0.440-0.875) and those without adverse SDOHs (0.635; 95% CI, 0.601-0.671) based on overlapping 95% CIs.

DISCUSSION

This study demonstrated that among Medicare beneficiaries, adverse SDOHs and race are independent predictors of lower rotator cuff surgery rates, emphasizing the need to address disparities based on race alone.

Risk Factors for All-Cause Early Reoperation Following Tumor Resection and Endoprosthetic Reconstruction: A Secondary Analysis from the PARITY Trial

BACKGROUND

Oncologic resection and endoprosthetic reconstruction of lower-extremity musculoskeletal tumors are complex procedures fraught with multiple modes of failure. A robust assessment of factors contributing to early reoperation in this population has not been performed in a large prospective cohort. The aim of the present study was to assess risk factors for early reoperation in patients who underwent tumor excision and endoprosthetic reconstruction, with use of data from the Prophylactic Antibiotic Regimens in Tumor Surgery (PARITY) trial.

METHODS

Baseline characteristics were assessed, including age, sex, tumor type, tumor location, presence of a soft-tissue mass, diabetes, smoking status, chemotherapy use, and neutropenia. Operative factors were recorded, including operative time, topical antibiotics, silver-coated prosthetics, endoprosthetic fixation, extra-articular resection, length of bone resected, margins, tranexamic acid, postoperative antibiotics, negative-pressure wound therapy, and length of stay. Univariate analysis was utilized to explore the differences between patients who did and did not undergo reoperation within 1 year postoperatively, and a multivariate Cox proportional hazards regression model was utilized to explore the predictors of reoperation within 1 year.

RESULTS

A total of 155 (25.7%) of 604 patients underwent ≥1 reoperation. In univariate analysis, tumor type (p < 0.001), presence of a soft-tissue mass (p = 0.045), operative time (p < 0.001), use of negative-pressure wound therapy (p = 0.010), and hospital length of stay (p < 0.001) were all significantly associated with reoperation. On multivariate assessment, tumor type (benign aggressive bone tumor versus primary bone malignancy; hazard ratio [HR], 0.15; 95% confidence interval [CI], 0.04 to 0.63; p = 0.01), operative time (HR per hour, 1.15; 95% CI, 1.10 to 1.23; p < 0.001), and use of negative-pressure wound therapy (HR, 1.93; 95% CI, 1.30 to 2.90; p = 0.002) remained significant predictors of reoperation within 1 year.

CONCLUSIONS

Independent variables associated with reoperation within 1 year in patients who underwent tumor resection and endoprosthetic reconstruction included tumor type (benign aggressive bone tumor versus primary bone malignancy), operative time, and use of negative-pressure wound therapy. These results will help to inform patients and surgeons regarding the risk of reoperation by diagnosis and reinforce operative time as a factor influencing reoperation. These results also support further investigation into the use of negative-pressure wound therapy at the time of surgery in this patient population.

LEVEL OF EVIDENCE

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Most Patients With Bone Sarcomas Seek Emotional Support and Information About Other Patients' Experiences: A Thematic Analysis

BACKGROUND

Online discussion forums allow individuals who otherwise may be strangers to create a community where they can seek and share information. Patients with bone sarcomas and their support networks use discussion forums dedicated to cancer support. There is a paucity of published reports regarding the care experience of patients with bone sarcomas because studies on online discussion groups have primarily focused on some of the more common cancers, including breast and prostate cancer. Understanding commonly discussed themes among patients with bone sarcomas would allow treating physicians to have a better understanding of patient concerns when providing patient education and counseling.

QUESTION/PURPOSE

We performed this study to review posts from bone sarcoma internet discussion boards to establish common themes related to the care experience of patients with sarcomas.

METHODS

Online discussion forums were identified using the search term "sarcoma discussion forum." After identifying 12 websites, we excluded closed forum groups, websites with missing or invalid links to forums, and nonpublic forums, such as groups on Facebook. These websites include profiles and photos that are personal, and sufficient author anonymity could not be achieved for this study. Posts written between January 1, 2012, and May 1, 2022, posted on five discussion boards were reviewed and collected until we reached a point of data saturation in which we agreed that the collection of additional posts would not reveal new themes. Discussion threads were filtered to identify posts pertaining to the most common bone sarcomas: chondrosarcoma, Ewing sarcoma, and osteosarcoma. Grounded theory-the methodology of repeated analyses of qualitative data to identify recurring themes or concepts-was used to analyze posts. Caregiver posts were delineated from patient posts and categorized separately for subgroup analysis. Grounded theory, although a qualitative method, endeavors to integrate the strengths inherent in quantitative methods with qualitative approaches. Grounded theory categorizes words, language, and the meanings these imply and seeks to organize and reduce the data gathered into themes or essences, which, in turn, can be fed into descriptions, models, or theories. Our analysis used three reviews of text to assign and group codes based on repeating ideas or concepts. The first review (open coding) aims to assign codes based on the verbatim text included by the author to capture the specific thoughts and ideas of the post. The second review (axial coding) aims to consolidate the ideas of posts by applying broader concepts to each post. The third and final review (selective coding) aims to further consolidate the themes of each post by trying to embody the main message contained in a post. A total of 570 posts from 139 threads were collected and analyzed using grounded theory. Twenty-five axial codes and four selective codes were created. We defined data saturation by the absence of a new open code in the analysis of a block of 50 posts to ensure that signals of saturation were not accepted too early in the analysis.

RESULTS

The four selective codes included emotional aspects or connecting with others, information support: diagnosis, information support: treatment, and information support: recovery. Of these four codes, emotional aspects and connecting with others was the most prevalent theme (78% [445 of 570] of posts) followed by information support: treatment (49% [282 of 570] of posts). Information support: diagnosis and information support: recovery were each captured in 15% of posts.

CONCLUSION

Analysis of posts reveals that the two most common themes involve seeking out emotional support and information about the experiences of others with various treatment modalities. Although most of the posts we assessed contained experiential information and emotional support rather than directed medical advice, future studies should assess the accuracy of information shared among online sarcoma forums.

CLINICAL RELEVANCE

Physicians caring for patients with sarcomas should not only address patient concerns related to medical care, but also provide emotional support directly and assist patients by providing resources to peer support outlets, including online discussion forums. Although we cannot ascertain the proportion of patients who use online sites given the anonymity of posts included, these findings suggest common experiential themes across patients with sarcomas outside their doctors' offices. It is important that providers be aware of reputable forums to provide as resources for their patients. The Musculoskeletal Tumor Society may further benefit from endorsing one or more of these forums and providing physician oversight to monitor misinformation.

What are the indications and survivorship of tumor endoprosthetic reconstructions for patients with extremity metastatic bone disease?

BACKGROUND AND OBJECTIVES

Given advances in therapies, endoprosthetic reconstruction (EPR) in metastatic bone disease (MBD) may be increasingly indicated. The objectives were to review the indications, and implant and patient survivorship in patients undergoing EPR for MBD.

METHODS

A review of patients undergoing EPR for extremity MBD between 1992 and 2022 at two centers was performed. Surgical data, implant survival, patient survival, and implant failure modes were examined.

RESULTS

One hundred fifteen patients were included with a median follow-up of 14.9 months (95% confidence interval [CI]: 9.2-19.3) and survival of 19.4 months (95% CI: 13.6-26.1). The most common diagnosis was renal cell carcinoma (34/115, 29.6%) and the most common location was proximal femur (43/115, 37.4%). Indications included: actualized fracture (58/115, 50.4%), impending fracture (30/115, 26.1%), and failed fixation (27/115, 23.5%). Implant failure was uncommon (10/115, 8.7%). Patients undergoing EPR for failed fixation were more likely to have renal or lung cancer (p = 0.006).

CONCLUSIONS

EPRs were performed most frequently for renal cell carcinoma and in patients with a relatively favorable survival. EPR was indicated for failed previous fixation in 23.5% of cases, emphasizing the importance of predictive survival modeling. EPR can be a reliable and durable surgical option for patients with MBD.

Impact of Patient and Tumor Characteristics on Range of Motion and Recurrence Following Treatment of Enchondromas of the Hand

PURPOSE

The approach to the treatment of enchondromas of the hand is varied, and there is no clear consensus on graft source, fixation, or need for intraoperative adjuvant therapy. We reviewed a cohort of patients who underwent curettage and bone grafting with cancellous allograft chips without internal fixation or adjuvant therapy and reported on postoperative range of motion (ROM) and recurrence rates.

METHODS

We performed a retrospective review of patients who underwent surgical treatment for hand enchondroma over a 23-year period. We collected information on demographics and presenting enchondroma characteristics, including Takigawa classification and presence of pathologic fracture or associated syndromes. Patients were treated with open biopsy with curettage and grafting with cancellous allograft chips. Postoperative ROM, complications, and recurrences were recorded.

RESULTS

Our series included 111 enchondromas in 104 patients. Seventeen of 104 patients (16%) had a diagnosis of Ollier disease. Average length of follow-up was 3.1 years. Eighty-one percent of patients achieved full ROM. Treatment of patients who presented with preoperative pathologic fracture resulted in a greater frequency of reduced postoperative ROM at 28% (9/32) compared to 15% (11/72) of those patients who did not present with preoperative pathologic fracture. Local recurrence developed in 5 of 50 (10%) patients with a minimum of 2 years of follow-up. Local recurrence occurred at higher-than-average rates in patients with giant form Takigawa classification (43%, 3/7) and Ollier disease (23%, 3/13).

CONCLUSIONS

Treatment of enchondromas with biopsy, curettage, and allograft results in full ROM in 81% of patients. Patients with preoperative pathologic fracture should be advised of a greater risk of postoperative extension deficit. Recurrence remains rare and is associated with syndromic presentation and giant form lesions.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Boston Carpal Tunnel Questionnaire Scores Alone Do Not Predict Surgical Intervention for Patients With Carpal Tunnel Syndrome

BACKGROUND

With the expanded indications for telemedicine, there is increased utility for screening methods to determine which patients are likely to progress to surgical intervention, requiring in-person visits. Patient-rated tools such as the Boston Carpal Tunnel Questionnaire (BCTQ) may be one such tool for screening patients with carpal tunnel syndrome (CTS). The aim of the study was to evaluate whether BCTQ scores were predictive of offering conservative treatment or surgical intervention for CTS.

METHODS

Patients diagnosed with CTS from January 2017 to February 2020 completed BCTQ questionnaires prior to in-person office visits. Demographics, comorbidities, and highest level of intervention recommended were recorded for each patient as conservative, injection, or surgery. Pearson χ2 and independent-samples t tests were conducted to determine whether BCTQ symptom severity and functional scores were associated with intervention type.

RESULTS

A total of 200 patients with CTS were included. Of these, 103 were recommended conservative or injection treatment and 97 were recommended surgery. There were no differences in comorbidities between groups, including other upper extremity pathology (P = .57), previous upper extremity surgery (P = .32), hypertension (P = .17), hypothyroidism (P = .15), rheumatoid arthritis (P = .34), and diabetes (P = .30). Between these groups, there were no differences in BCTQ symptom severity score (symptom severity scale [SSS]; P = .16) or BCTQ functional severity score (functional severity scale [FSS]; P = .96).

CONCLUSIONS

There is no correlation between comorbidities and BCTQ SSS or FSS score, and offering surgery for CTS. In an era of minimizing non-essential health care visits, the BCTQ is insufficient in screening patients as potential surgical candidates.

The Impact of Isolated Versus Multiple Osteochondromas: Analysis of the CoULD Registry

PURPOSE

The burden of upper extremity (UE) osteochondromas on function and self-perception among pediatric patients is unclear. The purpose of our study was to study the impact of osteochondromas in comparison to population norms and to evaluate solitary versus multiple osteochondromas on subjective UE function as measured by patient rated outcomes.

METHODS

We utilized the CoULD (Congenital Upper Limb Differences) Registry to review all pediatric patients presenting with osteochondromas between January 2014 and February 2021. Demographic information was collected and patients were classified as having either single or multiple osteochondromas. Patient-Reported Outcome Measurement Information System (PROMIS) and Pediatric Outcomes Data Collection Instrument (PODCI) tools were utilized for assessment. Scores for PODCI subscales of UE function, Pain/comfort, and Happiness and PROMIS domains of UE Function, Pain, Depression, Anxiety, and Peer Relations were reviewed. Differences between groups were analyzed using the Student t test.

RESULTS

Ninety-nine patients met inclusion criteria for the study with an average age of presentation of 9.3 years and 61 patients (62%) were male. Overall, patients demonstrated worse UE Function as well as greater Anxiety and Depression in comparison to the population normals on PROMIS assessment. Patients also demonstrated worse patient and parent reported PODCI UE, Sports and Physical Functioning, Pain/Comfort and Global Functioning scores compared with population norms but demonstrated better than average happiness scores. Patients with multiple osteochondromas demonstrated greater PROMIS pain interference and more disability in PODCI Sports and Physical Functioning, Pain/Comfort and Global Functioning compared with those with solitary osteochondromas.

CONCLUSION

Patients with UE osteochondromas have worse overall function in comparison to population norms, exceeding established minimally clinically important difference values. In addition, patients with multiple osteochondromas reported more pain and poorer physical function than those with solitary osteochondromas. Physicians should be alert to the physical and psychosocial burden of this disease.

LEVEL OF EVIDENCE

Level II-prognostic.

The Dorsal Ligament Complex: A Cadaveric, Histology, and Imaging Study

PURPOSE

The distinction between the dorsal intercarpal (DIC) and dorsal scaphotriquetral (DST) ligaments is imprecise and unclear in the literature. The purpose of our cadaveric study was to define the origins, insertions, and anatomic relationships of the dorsal wrist ligaments and relate these anatomic findings to magnetic resonance imaging (MRI) scans and histology.

METHODS

The study included 17 unmatched fresh-frozen cadaveric specimens (7 male and 10 female), with a mean age of 67.1 years (range, 48-86 years). Wrists with arthritis or carpal malalignment were excluded. Ligaments were dissected and insertion sites were recorded in the radioulnar (width) and proximodistal (length) dimensions, centered at the midpoints of the insertion. Three cadaveric specimens underwent a histologic analysis to demonstrate ligament composition and insertion sites. Three additional cadavers underwent MRI, from which 3-dimensional models were built to model ligament topography.

RESULTS

The conjoined triquetral insertion of the DIC, DST, and dorsal radiocarpal (DRC) measured 88.5 ± 6.4 mm². In each specimen, there were 2 distinct deep and superficial components of intercarpal fibers. The deep component inserted on the lunate with an area of 59.0 ± 5.0 mm². The deep and superficial components diverged as they coursed radially. The superficial component proceeded to the scaphoid ridge, trapezium, and trapezoid, whereas the deep component inserted on the proximal row. The deep fibers blended distally from their lunate insertion with the DST, forming a robust, 2.9 ± 0.8-mm wide extension over the dorsal capitate. The DRC inserted on the lunate, proximal to the DIC and DST insertions, with an area of 23.9 ± 5.4 mm².

CONCLUSIONS

The dorsal ligament complex forms a firm link across the proximal carpal row and the DST provides extension of the proximal row over the capitate.

CLINICAL RELEVANCE

This information can guide surgeons while performing a dorsal approach to the wrist and repairing traumatic ligament disruption.

Impact of Patient-Reported Allergies on Early Postoperative Opioid Use and Outcomes Following Ambulatory Hand Surgery

Background: Patient-reported allergies (PRAs) are associated with suboptimal orthopaedic surgery outcomes and may serve as a proxy for mental health. While mental health disorders are known risk factors for increased opioid use, less is known about how PRAs impact opioid use after orthopedic surgery. The purpose of this study was to investigate the association between PRAs and postoperative opioid use, pain, and satisfaction following hand surgery. Methods: Patients who underwent ambulatory hand surgery at a single institution from May 2017 to March 2019 were retrospectively reviewed. Various scores, including the Mindfulness Attention Awareness Scale (MAAS), were collected preoperatively. Postoperatively, patients completed a 2-week pain diary, satisfaction, and visual analog scale (VAS) pain scores. Opioid consumption was converted to oral morphine equivalents (OMEs) using standard conversions. Results: A total of 137 patients were divided into 2 groups based on presence (≥1) (n = 73) or absence (0) (n = 64) of PRAs. At baseline, the ≥ 1 PRA group had significantly higher female composition (P < .001) and pain (P < .001) and lower PROMIS mental health scores (P = .044). Postoperative OME consumption averaged 42.5 (range 0-416) in the entire cohort, with no differences between groups. Among patients with ≥ 1 PRA, increasing number of allergies significantly correlated with increasing OME consumption across all time points (week 1, P = .016; week 2, P = .001; total, P = .005). Conclusions: The presence of PRAs did not impact postoperative narcotic usage, pain, or satisfaction. Increasing numbers of PRAs did, however, significantly correlate with higher narcotic use. These results may have implications for postoperative pain management in this population.

Shoulder and elbow pathology in the female athlete: sex-specific considerations

Unique biologic and biomechanical aspects of the female body make women more prone to certain orthopedic injuries. Sex differences are well understood with regard to certain orthopedic pathologies such as anterior cruciate ligament injury, hallux valgus, carpal tunnel, and carpometacarpal joint arthritis; however, sex differences are less commonly discussed with regard to shoulder and elbow pathology. The purpose of this review is to elucidate sex differences specific to sports-related shoulder and elbow injuries in the female athlete population.

Prior Knee Arthroscopy Increases the Failure Rate of Subsequent Unicompartmental Knee Arthroplasty

BACKGROUND

In selected patients, knee arthroscopy is performed prior to unicompartmental knee arthroplasty (UKA) to treat symptomatic mechanical pathology, delay arthroplasty, and assess the knee compartments. The purpose of this study was to determine if knee arthroscopy prior to UKA is associated with increased rates of UKA failure or conversion to total knee arthroplasty (TKA).

METHODS

Data was collected from the Humana insurance database from 2007-2017. Patients who underwent knee arthroscopy within two years prior to UKA were identified and matched with controls based on age, gender, Charlson Comorbidity Index, smoking status, and obesity. Rates of conversion to TKA and failure for various causes were compared between cohorts.

RESULTS

Prior to propensity matching, 8353 UKA patients met inclusion criteria. Of these, 1079 patients (12.9%) underwent knee arthroscopy within two years of UKA and were matched to 1079 patients (controls) who did not undergo knee arthroscopy in the two years preceding UKA. No differences in demographics/comorbidities existed among cohorts. Compared to controls, the knee arthroscopy cohort was more likely to experience failure for aseptic loosening (2.4% vs 1.1%; OR 2.166; P = .044) and significantly more likely to require conversion to TKA (10.4% vs 4.9%; OR 2.113; P < .001) within two years of UKA.

CONCLUSION

Knee arthroscopy within two years of UKA is associated with an increased rate of UKA conversion to TKA and a higher rate of UKA failure from aseptic loosening. Although clinicians should be mindful of this association when performing knee arthroscopy in patients who may be indicated for future UKA, further research is needed to better characterize these findings.

Comparison of Revision Risk Based on Timing of Knee Arthroscopy Prior to Total Knee Arthroplasty

BACKGROUND

Knee arthroscopy may be performed prior to total knee arthroplasty (TKA) in patients with symptomatic degenerative knee changes that do not yet warrant TKA. The purpose of this study was to determine whether the time interval between knee arthroscopy and subsequent primary TKA is associated with increased rates of revision and certain complications following TKA.

METHODS

Data from 2006 to 2017 were collected from a national insurance database. Patients who underwent knee arthroscopy within 1 year prior to primary TKA were identified and stratified into the following cohorts based on stratum-specific likelihood ratio (SSLR) analysis: 0 to 15, 16 to 35, 36 to 43, and 44 to 52 weeks from the time of knee arthroscopy to TKA. Univariate and multivariable analyses were conducted to determine the association between these specific time intervals and rates of revision surgery, periprosthetic joint infection (PJI), aseptic loosening, and manipulation under anesthesia.

RESULTS

In total, 130,128 patients were included in this study; 6,105 (4.7%) of those patients underwent knee arthroscopy within 1 year prior to TKA and 124,023 (95.3%) underwent TKA without any prior knee surgery, including arthroscopy (the control group). Relative to the control group, the likelihood of undergoing revision surgery was significantly greater in patients who underwent knee arthroscopy ≤15 weeks (odds ratio [OR]: 1.79; 95% confidence interval [CI]: 1.43 to 2.22; p < 0.001) or 16 to 35 weeks (OR: 1.20; 95% CI: 1.01 to 1.42; p = 0.035) prior to TKA. Patients were at significantly increased risk for PJI if knee arthroscopy was done ≤35 weeks prior to TKA, and all 4 time groups that underwent knee arthroscopy within 1 year before TKA were at increased risk for manipulation under anesthesia.

CONCLUSIONS

We found a time-dependent relationship between the timing of knee arthroscopy and complications following TKA, with the prevalence of revision surgery and PJI increasing as knee arthroscopy was performed closer to the time of TKA. This study suggests that an interval of at least 36 weeks should be maintained between the 2 procedures to minimize risks of PJI and revision surgery.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Pre-operative Two-Point Discrimination Predicts Response to Carpal Tunnel Release

BACKGROUND

Limited evidence informs whether pre-operative values of two-point discrimination (2PD) in patients with carpal tunnel syndrome predict response to surgery.

QUESTIONS/PURPOSES

The primary aim of this study was to determine the predictive value of pre-operative 2PD scores on outcomes following carpal tunnel release (CTR). In particular, we sought to evaluate whether a clinically relevant 2PD threshold exists that can predict symptomatic response after surgery.

METHODS

Patients who underwent CTR between 2014 and 2018 were retrospectively reviewed. Static 2PD scores in each digit, as well as Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) and Levine-Katz scores, were collected from pre- and post-operative records. Pearson correlation coefficients assessed the relationship between pre-operative 2PD, early post-operative 2PD, and patient-reported outcome scores. Poor 2PD was defined as 2PD greater than 10 mm.

RESULTS

Eighty-nine hands in 73 patients with a mean follow-up of 1.8 years were analyzed. Mean pre- and post-operative 2PD was 7.2 mm and 6.4 mm, respectively, in the most affected digit when measurable. Twenty patients had poor 2PD scores pre-operatively and 14 post-operatively. There was a positive correlation between pre- and early post-operative 2PD scores but no correlation between pre-operative 2PD score and final post-operative functional scores. Only 30% of patients with poor pre-operative 2PD scores demonstrated improvement, compared with 69% of patients with measurable 2PD.

CONCLUSION

We found that greater pre-operative 2PD scores predicted greater early post-operative 2PD scores but did not lead to worse functional outcome scores post-operatively. Patients with poor pre-operative 2PD scores were likely to demonstrate improvement in functional outcomes scores, while having less reliable improvement in 2PD after CTR. Patients with poor 2PD should be counseled that improvement of tactile perception is less predictable.

Elbow contracture following operative fixation of fractures about the elbow

BACKGROUND

The rates of elbow contracture and contracture release after surgically treated elbow trauma are poorly defined. The purpose of this study was to define the incidence of elbow contracture diagnosis and release after surgical treatment for elbow trauma.

METHODS

The Humana insurance database was queried using the PearlDiver Patient Records Database between 2007 and 2017. Subjects were identified using International Classification of Diseases (ICD) codes in combination with Current Procedural Terminology codes and were included if they had a minimum of 1-year follow-up. Qualifying operative elbow trauma patients were queried for development of postoperative elbow contracture. Patient demographic characteristics, risk factors for elbow stiffness, and use of postoperative anticoagulation were recorded. Fracture severity was classified based on ICD-9 and ICD-10 codes. Logistic multivariate analysis was performed to determine independent risk factors for postoperative elbow contracture.

RESULTS

The study population included 10,672 patients who were surgically treated for elbow trauma. In total, 902 patients (8.4%) were diagnosed with a contracture following fracture. Of patients with a diagnosis of elbow contracture, 65 patients (7.2%) underwent contracture release. On average, time to contracture diagnosis was 3.6 months (SD 7 months) and time to contracture release was 8.4 months (SD 3.6 months). The use of postoperative anticoagulation, burn or head injury at the time of fracture, male sex, obesity, opioid use, and moderate or severe fracture severity were significantly associated with progression to elbow contracture.

CONCLUSION

The development of elbow contracture after surgical treatment of elbow trauma has a relatively high incidence of 8.4%.

The Effect of Plate Design on the Flexor Pollicis Longus Tendon After Volar Locked Plating of Distal Radial Fractures

BACKGROUND

Injury to and rupture of the flexor pollicis longus (FPL) tendon are known complications after volar locking plate fixation for distal radial fractures. Recent investigations have demonstrated that plate positioning contributes to the risk of tendon rupture; however, the impact of plate design has yet to be established. The purpose of this study was to compare FPL tendon-to-plate distance, FPL tendon-plate contact, and sonographic changes in the FPL tendon for 2 volar locking plate designs (ADAPTIVE compared with FPL) using ultrasound examination.

METHODS

We identified patients who underwent distal radial fracture fixation by 2 fellowship-trained hand surgeons with either standard (ADAPTIVE) or FPL plates. Patients were matched by age, sex, and Soong grade. Enrolled patients returned for a research-related office visit for a clinical examination and bilateral wrist ultrasound. We measured plate-tendon distance, plate-tendon contact, sonographic changes in the FPL tendon, and postoperative radiographic parameters in the operatively treated wrist and the uninjured wrist.

RESULTS

Forty patients with Soong grade-1 or 2 plate prominence underwent bilateral wrist ultrasound examination; all of the patients had distal radial fracture fixation, 20 with the standard volar locking plate and 20 with the FPL volar locking plate. Similar proportions of patients with the FPL plate (65%) and those with the standard plate (79%) had plate-tendon contact (p = 0.48); however, the FPL volar locking plate group had significantly less of the FPL tendon in contact with the volar plate than the standard volar locking plate group at wrist extension at both 0° (p < 0.001) and 45° (p < 0.001). There was no difference (p = 0.5) in the proportion of patients with sonographic changes in the FPL tendon between the FPL volar locking plate group (25%) and the standard volar locking plate group (21%). The postoperative volar tilt was significantly lower in patients with FPL plate-tendon contact (p = 0.01) and correlated moderately with the percentage of FPL tendon-plate contact at 0° (r = -0.51; p < 0.001) and 45° (r = -0.53; p < 0.001). There were no cases of tendon rupture in the cohort.

CONCLUSIONS

We found that the FPL volar locking plate and increased volar tilt significantly reduced the plate-tendon contact area compared with the standard volar locking plate. In our asymptomatic cohort, we were unable to find a difference in sonographic changes in the FPL tendon. Further studies are needed to determine the clinical importance of decreased tendon-plate contact area seen in modified volar locking plate designs.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of Levels of Evidence.

The Relationship Between Pain-Related Psychological Factors and Postoperative Opioid Use After Ambulatory Hand Surgery

PURPOSE

Pain-related psychological factors, including pain catastrophizing and dispositional mindfulness, have been shown to influence patient pain levels and outcomes after orthopedic surgery. Less is known about the relationship between these factors and postoperative opioid use after hand surgery. The purpose of this study was to examine the association between preoperative pain catastrophizing and mindfulness and postoperative opioid use in patients undergoing ambulatory hand surgery.

METHODS

Patients undergoing ambulatory hand surgery at our institution between May 2017 and January 2018 were prospectively enrolled in an ongoing clinical trial. Patients completed the Pain Catastrophizing Scale (PCS) and Mindfulness Attention Awareness Scale (MAAS) before surgery. Patients completed a pain medication diary for 2 weeks after surgery and were contacted on postoperative days 3, 8, and 15 to review their medication usage and pain levels. Analyses were performed to evaluate the association between PCS, MAAS scores, and postoperative opioid use, average patient reported pain levels, and refill rates.

RESULTS

A total of 85 patients were included in the analysis. Higher PCS scores (representing more pain catastrophizing) were associated with increased number of opioid pills consumed, higher average pain levels during the first postoperative week, and higher refill rates. Higher MAAS scores (representing more mindfulness) were associated with lower average week-1 pain levels but not significantly associated with opioid use or refill rates.

CONCLUSIONS

Patients demonstrating higher PCSs before surgery used more opioids after surgery after a range of ambulatory hand surgeries. In the setting of the opioid epidemic, hand surgeons should be aware of pain-related psychological factors that can influence postoperative opioid use.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

A CT-based approach with 3D modeling to determine optimal radiographic views of the scaphotrapezial and scaphotrapezoid joints

PURPOSE

To use a CT-based approach with 3D modeling to determine novel radiographic views of the scaphotrapezial (STl) and scaphotrapezoid (STd) joints.

MATERIALS AND METHODS

Consecutive wrist CT scans excluding those with pathology of the distal radius, scaphoid, trapezium, or trapezoid of subjects between ages 18 and 60 years were retrospectively reviewed. Three-dimensional reconstructions of CT scans were created and best-fit planes of the STl and STd joints were generated. Angles of these planes relative to a distal radial coordinate system were calculated to determine tilt of the wrist and the X-ray beam for novel radiographic views of these joints.

RESULTS

Fifty eligible wrist CT scans were identified. The mean age was 38 years (range, 18 to 59). For the novel STl PA view, the wrist is supinated 17° from the standard PA view and the X-ray beam is canted 6° caudad. In the STl lateral view, the wrist is pronated 17° from the standard lateral view, and the X-ray beam is canted 20° caudad. In the STd PA tilt view, the wrist is supinated 28° from the standard PA view, and the X-ray beam is canted 13° caudad. In the STd joint lateral tilt view, the wrist is pronated 28° from the standard lateral view, and the X-ray beam is canted 29° caudad.

CONCLUSION

We describe novel radiographic views of the STl and STd joints based on 3D modeling of wrist CT scans. Further studies are required to assess the efficacy of these views in detecting joint pathology.

Nerve Traction Injury After Subacute Revision External Fixation of a Tibial Plateau Fracture

Nerve traction injuries are common clinical entities that can be confused with nerve palsies secondary to alternate etiologies. Common mechanisms of nerve injury include direct laceration, crush injury, compression injury, elevated compartment pressures, or traction injury. Traction injuries commonly occur after trauma or aberrant patient positioning; however, traction injury following external fixation for lower extremity injury is rare. This case report describes a 42-year-old man who initially sustained a Schatzker VI tibial plateau fracture that required revision of external fixation for pin-site infection as soft tissues recovered from the initial trauma. Postoperatively, the patient experienced a nerve traction injury from lengthening after revision external fixation. Acute loss of common peroneal motor and sensory function was identified 1 hour postoperatively in the post-anesthesia care unit; this reversed on the immediate release of distraction from the external fixation construct. The patient's clinical course and the basic science principles underlying nerve traction injuries are discussed. Although traction injuries are rare after external fixation, orthopedic clinicians must understand them because early recognition can optimize outcomes. Knowledge of the biomechanical properties of peripheral nerves and their mechanisms of injury in such clinical settings may be useful for recognizing patients at risk for nerve traction injuries. [Orthopedics. 2018; 41(3):e434-e437.].

A pilot study for evaluation of hypotonia in children with neurofibromatosis type 1

There are currently no objective criteria to evaluate pediatric hypotonia. The purpose of this pilot study was to identify diagnostic criteria for assessing hypotonia in children with neurofibromatosis type 1. Fifty-five subjects between the ages of 1 and 7 years with a diagnosis of neurofibromatosis type 1 were evaluated. A physical therapist recorded a subjective tone assessment and objective tone metrics, including ankle dorsiflexion, knee extension, hip abduction, triceps fat percentage, grip strength, and head lag during a pull-to-sit test. Multivariate logistic regression analysis showed the presence of head lag paired with increased hip range of motion was a significant predictor of hypotonia. The presence of head lag on a pull-to-sit test paired with increased hip range of motion is an accurate predictor of hypotonia in children with neurofibromatosis type 1. These objective measures should be prospectively evaluated in other pediatric populations for their ability to predict hypotonia.

The association between hypotonia and brain tumors in children with neurofibromatosis type 1

Children with the neurofibromatosis type 1 (NF1) inherited tumor predisposition syndrome are at risk for the development of brain tumors. In addition, children with neurofibromatosis type 1 often exhibit low tone (hypotonia). In this study, the authors explored the hypothesis that hypotonia could be a clinical indicator of glioma in children with neurofibromatosis type 1. A total of 56 children between 1 and 7 years of age with a confirmed diagnosis of neurofibromatosis type 1 were evaluated. Brain magnetic resonance imaging (MRI) was available for 19 of these children. Chi-square analysis demonstrated a statistically significant correlation between hypotonia and glioma in children with neurofibromatosis type 1 (90% sensitivity and 78% specificity). These results suggest that hypotonia might be a clinically useful indicator of brain tumor in this at-risk population.

Longitudinal analysis of developmental delays in children with neurofibromatosis type 1

Children with neurofibromatosis type 1 exhibit a variety of developmental delays. However, there is little information about the progression of these deficits over the course of development. Using the Parents' Evaluation of Developmental Status measurement tool, we assessed 124 infants (0-2 years of age), preschool-age children (3-5 years of age), and school-age children (6-8 years of age) with neurofibromatosis type 1 to define the natural history of delays. School-age children exhibited significantly more areas of delay than infants or preschool-age children. Delays in math, reading, gross motor, fine motor, and self-help development were observed more frequently in older than younger children. Finally, analysis of 43 subjects for whom longitudinal assessments were available revealed that children often migrated between delayed and nondelayed groups in all areas except gross motor development. Based on these findings, we advocate early developmental screening and intervention for this at-risk pediatric population, especially in the area of gross motor function.

Epidemiology of carpal tunnel syndrome in patients with single versus multiple trigger digits

PURPOSE

Previous studies have identified the association between trigger digit and carpal tunnel syndrome (CTS). However, whether the presence of multiple trigger digits affects the prevalence of CTS is unknown. The purpose of this study was to determine the incidence of carpal tunnel symptoms in patients treated for single versus multiple trigger digits.

METHODS

We performed a retrospective review of 300 patients treated for trigger digit by injection or surgical release and recorded CTS symptoms, signs, and treatment for either the ipsilateral or contralateral hand documented within 24 months before trigger digit treatment and for an average of 35 months (range, 7- 66 mo) after treatment. Patients were categorized as having single (n = 160) or multiple (n = 140) trigger digits. Binary logistic regression modeled risk factors for development of CTS. Patient age, sex, number of trigger digits (single or multiple), and presence of diabetes, gout, thyroid disease, or thumb osteoarthritis were considered independent variables.

RESULTS

A total of 58 of 140 patients (41%) who presented with multiple trigger digits exhibited concomitant carpal tunnel symptoms, compared with 26 of 160 (16%) patients who presented with a single trigger digit. Significant independent predictors of CTS associated with trigger digits in the final regression model included multiple trigger digits (odds ratio = 3.6; subjects with multiple trigger digits had significantly higher odds of carpal tunnel presentation than subjects with a single trigger digit) and diabetes (odds ratio = 1.9; diabetic subjects had significantly higher odds of carpal tunnel presentation than nondiabetics).

CONCLUSIONS

A greater than 3-fold increase in the relative risk of CTS development exists in patients undergoing treatment for multiple trigger digits, compared with those undergoing treatment for a single trigger digit. Awareness of this association may aid in the early diagnosis and treatment of CTS in patients presenting with multiple trigger digits.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic III.